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Full vs Partial Dual Eligibility

By Ed Crowe | General Articles | 0 comment | 7 October, 2024 | 0

The recent changes to Medicare SEPs for full, partial and LIS only members has caused some people to ask questions about Full vs Partial Dual Eligibility.

Watch a quick YouTube video on the Dual eligible SEP changes

Full Dual Eligibility

Individuals who are eligible for both Medicaid and Medicare are dual eligible. In other words, To have full dual eligibility, it means you qualify for full Medicaid benefits from your state as well as Medicare. Medicare covers most healthcare benefits, although Medicaid pays some out-of-pocket costs such as premiums, copays, coinsurance and deductibles as well as long-term care.

Those who are dual eligible may qualify for a DSNP plan. A DSNP plan is a kind of Medicare Advantage plan that provides additional benefits not provided by Medicare or Medicaid.

Partial Dual Eligibility

If an individual is Partial dual eligible, it means their income level qualifies them for an MSP (Medicare Savings Program). Each state manages the MSPs using their Medicaid program. MSPs cover some Medicare costs, such as Part A & Part B premiums. It is important to note; partial dual eligibility doesn’t provide the same medical benefit coverage as full Medicaid.

Some individuals who qualify as partial dual may also qualify for a DSNP (Dual Special Needs) plan. Although Medicare pays most of the health care benefits, partial duals are responsible for out-of-pocket costs.

How a MSP helps partial duals

When Medicare enrollees receive medical care, Medicare doesn’t cover the entire cost of the services. There is usually an amount that’s left over. This amount is the beneficiaries’ responsibility and is called cost share or out-of-pocket cost and includes copays, coinsurance premiums and deductibles. This amount is the responsibility of the member. This who are enrolled in an MSP may receive help from Medicaid in paying for some of those costs. The amount of help (or cost sharing) received from Medicaid depends on income level and assets (such as real estate).

The 4 types of partial dual eligibles

QMB – Qualified Medicare Beneficiary

Members who receive help at the QMB level receive helps paying for premiums for Medicare Parts A & B as well as some cost shares for deductibles, copays and coinsurance.

SLMB – Specified Low Income Medicare Beneficiary

The SLMB program provides help with Part B premiums only.

QI – Qualified Individual

Those at the QI level receive help with Part B premium payments, these individuals may have a higher income than SLMB recipients.

QDWI – Qualified Disabled and Working Individuals

Individuals on QDWI program receive helps paying Medicare Part A premiums (hospital insurance) . This level of help applies to disabled individuals who have returned to work and lost their premium-free Medicare Part A coverage.

What is MACRA

By Ed Crowe | General Articles | 0 comment | 2 August, 2023 | 0

What is MACRA?

There are many acronyms in the Medicare insurance industry. So much so, that it can be hard to keep them all straight. It is helpful to focus on the vitally important ones. MACRA is one of those acronyms that any informed agent needs to know about in order to best serve their customer base. What is MACRA stand for?

MACRA stands for the Medicare Access and CHIP Reauthorization Act of 2015. This bipartisan piece of legislation was signed into law on April 16, 2015. It created what is known as a Quality Payment Program (QPP). The Quality Payment Program is an incentive program that replaced the Sustainable Growth Rate (SGR) formula that Medicare was using. The Sustainable Growth Rate would have made payment rates for participating Medicare physicians go down significantly, which would have caused problems in the industry. Instead, the Center for Medicare and Medicaid Services (CMS) is now using the Quality Payment Program.

There are two different ways that physicians can choose to participate in the Quality Payment Program.

The Merit-Based Incentive Payment System (MIPS). This means that physicians would be reviewed and their payment would be based on how well they perform.
Advanced Alternative Payment Models (APMs). For physicians who choose this route, they may earn Medicare Incentive Payments by participating in an innovative payment model rather than have their rate based on their reviewed merit.

Other things that MACRA accomplished, other than implementing the Quality Payment Program and doing away with the Sustainable Growth Rate, are as follows:

It changed the way that Medicare rewards physicians, which puts the onus on quality of service rather than volume of service.
Under the Merit-based Incentive Payment System (MIPS), many quality programs are streamlined.
Rewards physicians for participating in Advanced Alternative Payment Models (APMs).
MACRA also required CMS to remove social security numbers from Medicare ID cards by 2019, in an effort to prevent identity theft and increase security for their beneficiaries.